Home and Community-Based Services (HCBS) Experience Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10389 Home and Community-Based Services (HCBS) Experience Survey	Form and Instruction	New	Available
Response to OMB comments_9_18_12.doc	Supplementary Document	Uploaded 2012-09-28	Available
Supporting Statement - Part B-HCBS_9_13_12_clean.docx	Supporting Statement B	Uploaded 2012-09-28	Available
Attachment A Legal Justification (11 Mar 12).pdf	Supplementary Document	Uploaded 2012-07-26	Available
Supporting Statement - Part A-HCBS_9_13_12_clean.docx	Supporting Statement A	Uploaded 2012-09-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
203499	Home and Community-Based Services (HCBS) Experience Survey	Form and Instruction	New

ICR Details

OMB Control No: 0938-1186	ICR Reference No: 201207-0938-005
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Home and Community-Based Services (HCBS) Experience Survey
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 01/03/2013
	Date Received in OIRA: 07/27/2012
Terms of Clearance: CMS will resubmit this ICR when revisions have been completed.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The goal of this survey is to provide standard performance metrics for HCBS programs that are applicable to all populations served by these programs, including people with physical disabilities, cognitive disabilities, intellectual impairments, and/or disabilities due to mental illness. The assessment will enable HCBS programs to identify areas in which quality can be improved and provide CMCSC, state Medicaid programs, consumers and their families, consumer advocacy organizations, and other stakeholders with comparisons across HCBS programs.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 2701 Name of Law: Affordable Care Act
   US Code: 42 USC 2701 Name of Law: Adult Quality Health Measures
   US Code: 42 USC 3011 Name of Law: National Quality Strategy
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 2701 Name of Law: Affordable Care Act
US Code: 42 USC 2701 Name of Law: Adult Quality Health Measures
US Code: 42 USC 3011 Name of Law: National Quality Strategy

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 29644	05/18/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 43288	07/24/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Home and Community-Based Services (HCBS) Experience Survey	CMS-10389, CMS-10389, CMS-10389	Attachment B Survey Instruments ,   Consent Form Spanish ,   Consent Form English

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection.

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Annual Cost to Federal Government: $272,282

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/27/2012

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